Individualizing MS Treatment: Risk Stratification, Biomarkers, and Patient Preference

In "Individualizing MS Treatment: Risk Stratification, Biomarkers, and Patient Preference," our experts turn to the tools that can personalize treatment selection and monitoring.

Dr. Freeman explains how adopting serum biomarkers two years ago changed her view of disease activity beyond clinical and MRI markers. These tools make her more comfortable following patients who decline high-efficacy therapy, which is why reimbursement and clinic access matter.

She notes that the pendulum swung toward early high-efficacy treatment, but clinicians cannot continue it for 20 or 30 years. Checking immunoglobulins at baseline can uncover immunodeficiencies, and a patient with one may be better suited to a different high- or moderate-efficacy option. She emphasizes individualized initiation and monitoring.

Dr. Longbrake adds that the best treatment is the one a patient will take. If someone accepts teriflunomide but refuses ocrelizumab, she will use teriflunomide and watch more closely. She asks patients what they could build into their lives without being bothered by it, because a drug not taken will not work.

Dr. Newsome cautions that known risk factors for long-term disability come from retrospective studies of individual characteristics. It remains unknown which features, such as spinal cord presentation or race, carry the greatest risk. He would like a Framingham-style score for MS that combines clinical, imaging, and biomarker data, as Canadian groups have started to do.

He also wonders whether patients with 20 or more lesions at presentation are the ones for whom the horse is already out of the barn. Patients with optic neuritis might benefit most from aggressive tissue preservation. High lesion burden might point toward a BTK inhibitor up front, though he calls this hard to say.

Dr. Nair summarizes that treat early, treat aggressively is no longer the only approach. She describes the large toolbox of generics, symptomatic drugs, infusions, orals, and subcutaneous options.

The next episode in this series, "Defining High-Efficacy MS Therapy: Access, Formularies, and Patient Choice," features the panel defining high efficacy and describing how formularies limit their toolbox.